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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Postmenopausal bleeding (486)

Please report any inaccuracies or issues with this guideline using our online form

Post menopausal Bleeding (PMB) is defined as unscheduled bleeding after one year of amenorrhoea. Women with this symptom are at increased risk of endometrial cancer and require urgent assessment. 

Referral

Patients with PMB should be seen within 2 weeks of referral to allow compliance with the 62 day National Guideline on cancer treatment times. To facilitate this all PMB referrals should be upgraded to ‘Urgent’ when letters are vetted. Where possible, patients should be assessed at a dedicated PMB/ one-stop clinic.

History

A full medical history is required including smear history. Particular attention should also be paid to drug history including HRT use, current or past tamoxifen use and use of anticoagulants such as warfarin, heparin and clopidogrel which many women take for cardiac problems.

Examination

All women with PMB should undergo speculum and bimanual pelvic examination. This can be facilitated by use of a virgin speculum. Patients should have an EUA if, despite these measures, examination proves impossible

Investigation

The initial investigation of choice is the measurement of endometrial thickness by transvaginal ultrasound scan. Endometrial biopsy is reserved for those women whose endometrial thickness exceeds a specified cut-off as follows:

  • Group 1: Women who have never used any HRT OR have not used HRT for more than one year OR are using continuous combined HRT.

Endometrial biopsy is required if the endometrial thickness exceeds 3mm.

  • Group 2: Women who are using sequential HRT OR have done so in the past year.

Endometrial biopsy is required if the endometrial thickness exceeds 5mm.

If the histology report in either group states ‘insufficient tissue for analysis’ and the ET has been thickened then the patient should have a hysteroscopy, if this hasn’t already been done, and a repeat biopsy.

  • Group 3:  Women who are current users of tamoxifen.

Tamoxifen is associated with distortion of the endometrial architecture.

Consequently, ultrasonography is a poor means of detecting endometrial cancer in this group. All such women should undergo hysteroscopy and endometrial biopsy.

Other Issues

  • This guideline refers to women who present with PMB for the first time. Those with recurrent symptoms after 6 months should be re-investigated, and women with persistent bleeding within 6 months of initial investigation should undergo hysteroscopy and endometrial biopsy.

  • There is no published evidence regarding the assessment of PMB in women taking Selective Estrogen Receptor Modifiers (SERMs) other than tamoxifen, eg Raloxifene. It is recommended that the precautionary principle applies and these women be treated in the same way as those taking tamoxifen i.e. undergo hysteroscopy and endometrial biopsy.

  • Transabdominal ultrasound scan may be used as a complementary investigation e.g. if the uterus is particularly enlarged or a wider view of the abdomen is required. It may also be used in the assessment of the small number of women in whom transvaginal scanning is technically impossible.

  • There is no evidence to support the use of endometrial thickness measurements and the associated cut-offs in the assessment of women with peri-menopausal bleeding. These women should undergo clinical evaluation as per menstrual disorder patients.

  • If an IUS or IUCD is in situ, patients should undergo transvaginal scan and biopsy. The coil may be left in place but will compromise the validity of ET measurements (hence the need for biopsy).

  • Endometrial biopsy is also required if:
    • there is an incomplete/poor view on ultrasound i.e the endometrial stripe is not seen along its length.
    • there is fluid within the endometrial cavity.
    • there is irregularity of the endometrial echo, regardless of the ET measurement. These women should also undergo hysteroscopy.

The preceding version of this GG&C guideline referenced SIGN guideline No.61 – The Investigation of Postmenopausal Bleeding (2002). This was withdrawn in February 2015. In the absence of any current national guidance, this revised version refers to current good practice standards. 

Editorial Information

Last reviewed: 14/07/2022

Next review date: 14/07/2025

Author(s): Morton Hair.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 486